Yield of practice-based depression screening in VA primary care settings.
ABSTRACT Many patients who should be treated for depression are missed without effective routine screening in primary care (PC) settings. Yearly depression screening by PC staff is mandated in the VA, yet little is known about the expected yield from such screening when administered on a practice-wide basis.
We characterized the yield of practice-based screening in diverse PC settings, as well as the care needs of those assessed as having depression.
Baseline enrollees in a group randomized trial of implementation of collaborative care for depression.
Randomly sampled patients with a scheduled PC appointment in ten VA primary care clinics spanning five states.
PHQ-2 screening followed by the full PHQ-9 for screen positives, with standardized sociodemographic and health status questions.
Practice-based screening of 10,929 patients yielded 20.1% positive screens, 60% of whom were assessed as having probable major depression based on the PHQ-9 (11.8% of all screens) (n = 1,313). In total, 761 patients with probable major depression completed the baseline assessment. Comorbid mental illnesses (e.g., anxiety, PTSD) were highly prevalent. Medical comorbidities were substantial, including chronic lung disease, pneumonia, diabetes, heart attack, heart failure, cancer and stroke. Nearly one-third of the depressed PC patients reported recent suicidal ideation (based on the PHQ-9). Sexual dysfunction was also common (73.3%), being both longstanding (95.1% with onset >6 months) and frequently undiscussed and untreated (46.7% discussed with any health care provider in past 6 months).
Practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. The substantial level of comorbid physical and mental illness among PC patients precludes solo management by either PC or mental health (MH) specialists. PC practice- and provider-level guideline adherence is problematic without systems-level solutions supporting adequate MH assessment, PC treatment and, when needed, appropriate MH referral.
- SourceAvailable from: Karen Jansen[Show abstract] [Hide abstract]
ABSTRACT: BACKGROUND: Depression, an important global health problem, negatively impacts the lives of individuals and their families beyond simply increasing the demand for health services. OBJECTIVE: To assess the prevalence of depression and associated mental health issues in individuals older than 14 years of age seeking primary care. METHODS: A cross-sectional study was conducted in three primary care units involved with the Catholic University of Pelotas. Depression, anxiety disorders, and suicide risk were assessed using the Mini International Neuropsychiatric Interview (MINI). Factors such as age, gender, solitary living, education, and psychoactive substance use were evaluated using a sociodemographic questionnaire. RESULTS: The overall prevalence of depression was 23.9% (n = 256). Depression was more prevalent in women with only 4-7 years of education, in women who belong to socioeconomic class D or E, in those who abuse or are dependent on alcohol, or in women who showed an anxiety disorder or suicide risk (p < 0.050). DISCUSSION: Based on these findings, we emphasize the integration of mental health care into primary care through diagnostic evaluations and treatment protocols that cover depression and its comorbidities.Revista de Psiquiatria Clínica 12/2011; 39(6):194-197. · 0.63 Impact Factor
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ABSTRACT: Clinical practice guidelines frequently recommend systematic screening for depression in cancer patients to improve recognition and prompt appropriate management. We aimed to screen major depressive disorder (MDD) in cancer inpatients using a structured tool and explore its applicability. Cancer inpatients were routinely screened by nurses using the Taiwanese Depression Questionnaire (TDQ), and for those screened positive, this was followed by a non-mandated referral to a psychiatrist for clinical evaluation and diagnosis. Patients who completed this two-stage procedure comprised the analysis sample. Routine screening of 8800 patients in a period of 27 months yielded 1087 (26.9%) positive first-time screens. Of them, 298 (27.4%) completed the psychiatric consultation. Depressive disorders were diagnosed in 185 patients (62.1%), mainly adjustment disorder (23.8%) and MDD (21.5%). The estimated prevalence of MDD was 21.5%. Area under the curve was 0.72, a result produced by the receiver operating characteristic curve of the TDQ scores relative to the clinical psychiatric diagnoses of MDD. A TDQ cutoff score of ≧26 provided an optimal diagnostic accuracy for MDD. This two-stage depression screening and diagnosing strategy is practical for improving recognition of MDD and other depressive disorders in cancer patients and could be routinely applied, rather than selectively, in a comprehensive cancer care system. Copyright © 2014 John Wiley & Sons, Ltd.Psycho-Oncology 05/2014; · 3.51 Impact Factor
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ABSTRACT: Objective Primary care screening programs for mental health disorders are designed to detect patients who might benefit from treatment. As such, the utility of these programs is predicated on the actions that take place in response to a positive screen. Our objective was to characterize the cascade of care delivery steps following a positive screen for a mental health disorder. Method We examined the care received by primary care patients over the year following a new positive screen for depression, PTSD, or alcohol misuse. We characterized whether the care adhered to practice guidelines for related mental health disorders and whether involvement of mental health specialists led to higher use of guideline-adherent practices. Results Many patients received appropriate treatment in the primary care setting and those whose scores were consistent with more severe illness were more likely to receive care in a mental health setting. Patients with positive screens for depression and PTSD who went on to be seen in mental health clinics received care that was consistent with treatment guidelines for the related disorder most of the time. In the case of patients with positive screens for alcohol misuse, few received guideline-recommended medications in any setting. However, a substantial portion of patients received some alcohol-related counseling from their primary care physicians during the visit in which their alcohol misuse was detected. Conclusion It appears that the treatment system for mental health problems, which extends from primary care settings to mental health sub-specialty settings, can provide adequate care when patients’ mental health problems are identified through screening. The care provided in all settings can be improved, and additional steps to enhance the quality of care are warranted. This should include additional efforts to align screening and treatment.General Hospital Psychiatry. 01/2014;
Yield of Practice-Based Depression Screening In VA Primary
Elizabeth M. Yano, PhD, MSPH1,2, Edmund F. Chaney, PhD3,4, Duncan G. Campbell, PhD5,
Ruth Klap, PhD1, Barbara F. Simon, MA1, Laura M. Bonner, PhD3,4, Andrew B. Lanto, MA1,
and Lisa V. Rubenstein, MD, MSPH1,2,6,7,8
1VA Greater Los Angeles Center of Excellence for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Healthcare System,
Sepulveda, CA, USA;2Department of Health Services, UCLA School of Public Health, Los Angeles, CA, USA;3Northwest Center for Outcomes
Research, VA HSR&D Center of Excellence, VA Puget Sound Healthcare System, Seattle, WA, USA;4University of Washington, Seattle, WA, USA;
5Department of Psychology, University of Montana, Missoula, MT, USA;6Department of Medicine, VA Greater Los Angeles Healthcare System,
Sepulveda, CA, USA;7Department of Medicine, UCLA School of Medicine, Los Angeles, CA, USA;8, RAND Health, Santa Monica, CA, USA.
BACKGROUND: Many patients who should be treated
for depression are missed without effective routine
screening in primary care (PC) settings. Yearly depression
screening by PC staff is mandated in the VA, yet little is
known about the expected yield from such screening
when administered on a practice-wide basis.
OBJECTIVE: We characterized the yield of practice-based
screening in diverse PC settings, as well as the care needs
of those assessed as having depression.
DESIGN: Baseline enrollees in a group randomized trial
of implementation of collaborative care for depression.
PARTICIPANTS: Randomly sampled patients with a
scheduled PC appointment in ten VA primary care clinics
spanning five states.
MEASUREMENTS: PHQ-2 screening followed by the full
PHQ-9 for screen positives,with standardized sociodemo-
graphic and health status questions.
RESULTS: Practice-based screening of 10,929
patients yielded 20.1% positive screens, 60% of
whom were assessed as having probable major
depression based on the PHQ-9 (11.8% of all
screens) (n=1,313). In total, 761 patients with prob-
able major depression completed the baseline assess-
ment. Comorbid mental illnesses (e.g., anxiety, PTSD)
were highly prevalent. Medical comorbidities were
substantial, including chronic lung disease, pneumo-
nia, diabetes, heart attack, heart failure, cancer and
stroke. Nearly one-third of the depressed PC patients
reported recent suicidal ideation (based on the PHQ-
9). Sexual dysfunction was also common (73.3%),
being both longstanding (95.1% with onset >6 months)
and frequently undiscussed and untreated (46.7%
discussed with any health care provider in past
CONCLUSIONS: Practice-wide survey-based depres-
sion screening yielded more than twice the positive-
screen rate demonstrated through chart-based VA per-
formance measures. The substantial level of comorbid
physical and mental illness among PC patients precludes
solo management by either PC or mental health (MH)
specialists. PC practice- and provider-level guideline
adherence is problematic without systems-level solutions
supporting adequate MH assessment, PC treatment and,
when needed, appropriate MH referral.
KEYWORDS: depression; screening; primary care; health care delivery;
J Gen Intern Med 27(3):331–8
© Society of General Internal Medicine 2011
Nationally, depression affects between 16–20 million Americans
and remains a major public health problem.1Despite its preva-
lence, depression often remains undetected, under-diagnosed
and under-treated.2–4Many depressed patients only contact the
healthcare system through primary care (PC).4Fortunately, more
efficient procedures for screening for and diagnosing depression
and the advent of better-tolerated antidepressants that are safer
and easier to prescribe (i.e., less complex dosing regimens) have
increased PC providers’ ability to manage mild to moderate
depression.5Nonetheless, PC-based detection and treatment
remain low.6Despite US Preventive Task Force recommendations
for practice-based screening of all PC patients, just 21% report
actually being screened.7,8Thus, many patients who should be in
treatment are missed without effective routine screening, while
screening also reveals that many patients who are in treatment
are still symptomatic.8
Despite treatment advances and widespread acknowledgment
of the value of PC-based management of depression, little is
known about the potential yield of depression screening guide-
lines in routine practice settings. What proportion of PC patients
actually screen positive and are assessed as having depression?
What are depressed PC patients’ physical and mental health care
needs? What are the implications of these rates and health care
needs for practicing PC providers?
Using practice-wide, population-based screening and assess-
ment, we randomly sampledPC patients from ten diverse primary
Received December 30, 2010
Revised June 28, 2011
Accepted September 16, 2011
Published online October 6, 2011
care settings from a large multisite randomized trial to discern
answers to these questions.
We engaged ten PC clinics in three VA regional networks across
five states (Florida, Ohio, South Dakota, Texas, Wisconsin).
Participating clinics spanned rural and metropolitan areas,
hospital- and community-based outpatient clinics, and teaching
and non-teaching programs. Practices ranged in size from 4–13
PC providers and in annual workloads from 3,900-13,000
approved the study.
Study Design and Sample
To characterize the yield of depression screening in routine
practice, we used the baseline cohort of patients enrolled in a
group randomized controlled trial evaluating practice-level
impacts of implementation of collaborative care for depression
from 2002–2004.10,11All PC patients who attended a study
clinic in the previous 12 months and who had an upcoming
appointment were eligible for inclusion regardless of age,
gender, race-ethnicity or health status, as depression screen-
ing guidelines make no demographic or comorbidity distinc-
tions. We excluded patients whose visits were scheduled for
compensation-and-pension exams (i.e., eligibility determina-
tion) or for visits without seeing the PC provider (e.g.,
Data Collection and Patient Survey Measures
Participating sites provided contact information for random
samples of eligible PC patients to an independent survey
research firm (California Survey Research Services, Inc., Van
Nuys, CA). Patients were notified of the study by mail 10 days
prior to telephone contact using letters from their respective
Primary Care Directors or Chiefs of Staff. We included
preaddressed refusal postcards and a toll-free number for
patients to call for refusal. After 10 days, trained interviewers
contacted patients via computer-assisted telephone interview-
We screened patients for depression using the Patient Health
Questionnaire-2 (PHQ-2), a two-item depression screener with
high sensitivity and specificity for major depressive disorder
(MDD).12–16Major depressive disorder (MDD) is characterized
by a “combination of symptoms that interfere with a person’s
ability to work, sleep, study, eat, and enjoy once-pleasurable
activities.”17We administered the remaining seven items of the
PHQ-9, which cover additional DSM-IV criteria for a major
depressive episode, to patients with affirmative responses to one
orbothPHQ-2items. The PHQ-9 hashighspecificityand positive
predictive value for MDD, and has been validated for telephone
administration.18,19Individuals with aggregated PHQ-9
scores≥10 were considered to have probable major depression,
and were thenconsented,enrolled and interviewed. All measures
are based on patient self-report.
We asked about patients’ demographics (age, gender,
race, ethnicity, relationship status), socioeconomic status
(employment, education, insurance), general health, func-
and medical comorbidity.22
assessed mental health (MH) comorbidities, including post-
traumatic stress disorder (PTSD), bipolar disorder, anxiety/
panic and alcohol abuse,23–26and depression modifiers
(e.g., dysthymia). Tables 1 and 2 provide measurement
definitions and details.
We used univariate analyses to describe the yield of depression
screening and assessment and the self-reported health status,
medical and MH comorbidities and function of PC patients
with probable major depression (PHQ-9≥10). CATI methods
resulted in little missing data, precluding the need for data
imputation methods (i.e., the majority of variables had 99%
valid data, with the exception of sexual dysfunction with 11%
missing). We report unadjusted frequencies; use of enrollment
weights (by age, sex, race-ethnicity) did not influence study
Practice-Based Sample Characteristics
and Response Rates
Overall, we received contact information on 28,474 randomly
sampled patients with upcoming PC appointments who had
had at least one visit in the previous 12 months (Fig. 1). These
individuals were predominantly male (95.1%) with a mean age
of 66.6 years (±12.4, range 21–105). Of those contacted,
10,929 completed the initial screen (73.9%). Of those assessed
(PHQ-9≥10), 761 (58.0%) enrolled and completed the baseline
Prevalence of Depression and Patient
Practice-based screening of 10,929 PC patients yielded
20.1% positive PHQ-2 depression screens (n=2,195, includ-
ing positive screens among 73 refusals post-consent-and-
screen) across the ten participating PC clinics (Fig. 1).
Among PHQ-2 positive screens, 59.8% (n=1,313) scored 10
or higher on the PHQ-9 (11.8% of all screens) and were
deemed to have probable major depression.27Of these
patients, 761 (58.0%) enrolled in the study, completed the
baseline assessment and are the focus of these results.
These depressed PC patients (PHQ-9≥10) were, on average,
60 years old, male, predominantly white and married, with
a high school or college education (Table 1). Two-thirds
were either disabled or permanently retired. Few lived
We found substantial evidence of dysthymia and chronic
major depression (Table 2). For example, 72.8% of depressed
Yano et al.: Yield of VA Depression Screening
veterans in PC reported experiencing at least one period of 2+
years when they felt depressed or sad most days. Over two-
thirds reported a period of 2+ weeks of feeling sad, empty or
depressed most of the day nearly every day in the past
12 months. About three-quarters of the patients reported
experiencing a similar amount of time suffering anhedonia
(i.e., lost interest in work, hobbies and other previously
enjoyed activities). Over half reported that their emotional
state conferred serious functional impairment in their ability
to work and/or take care of themselves or their families for 2+
weeks in the past 12 months. Nearly one-third reported
experiencing thoughts of suicide several days out of the
previous 2 weeks.
Medical and Mental Health Comorbidities among
Depressed Primary Care Patients
Medical and MH comorbidities were substantial (Table 2).
Table 1. Characteristics of Depressed Primary Care Patients with
Probable Major Depression (PHQ-9 ≥10) Identified through VA
Primary Care Practice-Based Screening
CharacteristicsDepressed primary care
Gender (% male)
Age (mean ± SD) (years)
Race (% white)
Married or living as married
Divorced or separated
Working full/part time for pay
Highest level of schooling
Elementary or junior high school
High school (or GED)
Associate or vocational school
Some postgraduate work or degree
Insurance status and reliance on VA
Have any insurance to cover costs
of medical care
Health care utilization
Received care at VA for physical or
emotional problems in past 6 months
General health status
Depression symptomatology* (% several days, more than half
the days or nearly everday in the past 2 weeks) (first two items,
PHQ-2; full item set, PHQ-9)
Over the last 2 weeks, how often have you been bothered by:
Feeling little interest or pleasure
in doing things
Table 1. (Continued)
CharacteristicsDepressed primary care
Feeling down, depressed or hopeless
Trouble falling or staying asleep,
or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself, or feeling that
you are a failure or have let yourself
or your family down
Trouble concentrating on things,
such as reading the newspaper
or watching television
Moving or speaking so slowly that
other people could have noticed. Or the
opposite—being so fidgety or restless
that you have been moving around a
lot more than usual
Thoughts that you would be better off dead
or of hurting yourself in some way
Suicidality protocol completed†
*Depression symptomatology was measured using the PHQ-9.18The
PHQ-2 (two-item screener) asks about frequency of anhedonia (i.e.,
feeling little interest…) and depressed mood (i.e., feeling down,
depressed, hopeless). The remaining seven items comprise the rest
of the PHQ-9, which uses the same 4-point scale (not at all, several
days, more than half the days, nearly everyday) regarding the past
2 weeks. Higher scores reflect worse symptomatology. PHQ-9 aggregated
scores ≥10 reflect probable major depression. Major depressive disorder
(MDD) is characterized by a “combination of symptoms that interfere with a
person’s ability to work, sleep, study, eat, and enjoy once-pleasurable
†We developed a suicidality protocol, which was triggered among
patients who responded to the ninth item of the PHQ-9 on suicidal
ideation: “How often have you been bothered by thoughts that you
would be better off dead or of hurting yourself in some way?” with
answers of “several days,” “more than half the days” or “nearly
every day,” and/or divulged thoughts of suicide, self-harm, persistent
thoughts of death or harm to others during the course of the interview.
Details of the suicide protocol are available elsewhere.12(Note: Thirty
patients were identified as acutely suicidal during the baseline
interview, were connected with mental health services and excluded
from the study)10
Table 2. Physical and Mental Health Comorbidities among Patients
with Probable Major Depression (PHQ-9 ≥10) Identified Through VA
Primary Care Practice-Based Screening
Has a doctor or nurse ever told you that
you had any of the following
Chronic lung disease, emphysema,
asthma or bronchitis
Congestive heart failure
Seattle Index of Comorbidity (SIC)*
Mental health comorbidity
Possible dysthymia and chronic
Yano et al.: Yield of VA Depression Screening
Table 2. (Continued)
Characteristics Depressed primary
Have you ever had a period of 2 years or
more in your life when you felt depressed
or sad most days, even if you felt
Of those who said yes, Did any period like
that ever last 2 years without an interruption
of 2 full months when you felt OK?
In the past 12 months, have you had 2 weeks or longer when:
Nearly every day you felt sad, empty or
depressed for most of the day
You lost interest in most things like
work, hobbies and other things you
Your emotional state seriously interfered
with your ability to do your job, take care
of your house or family, or take care
Last time drank alcohol:
Past 2 weeks
Between 2 weeks and 1 year ago
1 or more years ago
Alcohol Use Disorders Identification Test
(AUDIT-C) score25,26(mean ± SD)
Posttraumatic stress disorder (PTSD)§
Reexperiencing: Ever had any experience
in your life that was so frightening,
horrible or upsetting that you had
recurring nightmares about it or
continually thought about it when
you did not want to
Of those who said yes, proportion that had
had these thoughts or nightmares
in the past month
Avoidance: Had any experiences that were
so frightening, horrible or upsetting that
you repeatedly tried hard not to think
about it or repeatedly went out of your way
to avoid situations that reminded you of it
Of those who said yes, proportion that tried to
avoid these situations in the past month
Hypervigilance: Ever had a period where
you felt constantly on guard, watchful or
easily startled because of a frightening,
horrible or upsetting experience
Of those who said yes, proportion that had
this feeling of watchfulness in the past month
Emotional numbing: Ever had a period
where you felt numb or detached from
other people, activities or from your
surroundings because of a frightening,
horrible or upsetting experience
Of those who said yes, proportion with
feeling of detachment in past month
Doctor told you had a manic-depressive
or bipolar illness
Ever taken medications lithium, Depakote,
or Tegretol for a depressive illness
Felt anxious much of the time
(past 6 months)
Had panic attack when suddenly felt
intense fear and discomfort (past 6 months)
Of those who said yes, had a month or
more when they changed everyday
activities because of fear of having
another panic attack
Table 2. (Continued)
Panic attack within the past month
Physical and mental function¶
In past 4 weeks, all or most of the time:
Accomplished less than you would have
liked because of physical health
Limited in kinds of work or other activities
that you were able to do because
of physical health
Cut down the amount of time you spent
on work or other activities because of
Accomplished less than you would have
liked because of emotional problems
Did work or other activities less carefully
than usual because of emotional problems
Physical or emotional problems interfered
with your social activities (like visiting
friends, relatives, etc.)
Pain interfered with normal work
(including both work outside the home and
housework) quite a bit-to-extremely
Frequency of feeling (all-to-most of the time):
Felt so down in the dumps that nothing
could cheer you up
Felt calm and peaceful
Felt downhearted and depressed
Had a lot of energy
Satisfaction with level of daily activity
(dissatisfied-to- very dissatisfied)
Current difficulty with how you function
sexually or with your sexual activity
Among those with difficulty, difficulty first
started more than 6 months ago
Among those with difficulty, difficulty
bothers you moderately to very much
Among those with difficulty, ever discussed
difficulty with any health care provider
within past 6 months in person or by phone
*We measured medical comorbidities using the Seattle Index of Comor-
bidity (SIC), which combines the presence or absence of seven chronic
illnesses (listed above), cigarette smoking status and participant age into
an aggregated index. The SIC has been shown to predict hospitalization
†Dysthymia is characterized by long-term depressive symptoms (2+
years) that is typically less severe than major depressive disorder (MDD)
but may still prevent aspects of normal function or well-being; dysthy-
mics may also have 1+ episodes of major depression over their
‡We used the Alcohol Use Disorders Identification Test consumption
items (AUDIT-C) to evaluate alcohol consumption. Summed scores result
in an index where higher scores reflect higher consumption, which
predicts poor alcohol-related outcomes, while scores greater than 8 are
associated with mortality among male veteran VA outpatients65
§We used the Primary Care PTSD Screen (PC-PTSD) to detect probable
PTSD in primary care. The PC-PTSD may be used to generate a summary
score (0 to 4) for the presence of each of four PTSD symptoms
(reexperiencing, avoidance, hypervigilance and emotional numbing
related to past trauma), where scores of 3 and 4 represent positive PTSD
║We used positive responses to two questions (noted above) to identify
probable bipolar disorder.24The medications mentioned (e.g., lithium)
may be used as mood stabilizers for bipolar disorder
¶We drew items from the Short-Form 12 Survey (SF-12) of the Medical
Outcomes Study’s Short Form 36-item survey to assess functional
limitations related to physical and emotional health concerns, including
Yano et al.: Yield of VA Depression Screening
Medical comorbidities. Over one-third of depressed PC patients
reported histories of chronic lung disease, pneumonia and
diabetes, and about one-quarter reported a history of heart
attack. Roughly one in six reported congestive heart failure or a
history of cancer or stroke. Eighty percent of patients described
their general health as fair or poor. Their prior month’s
medication volume (6.9±5.5) corroborated their self-reported
PTSD. Over two-thirds of the sample reported lifetime
posttraumatic reexperiencing phenomena (i.e., recurrent
nightmares/intrusive thoughts) related to a past traumatic
event, with two-thirds of those reporting these experiences in
the past month. Similarly, about two-thirds reported
posttraumatic avoidance of thoughts or cues related to past
traumatic events; about half of these patients reported
avoidance behavior in the past month. Nearly 60% reported a
period of hypervigilance, with over 40% reporting these
experiences in the past month. Slightly over half experienced
emotional numbing or a sense of detachment from other
people, activities or surroundings, many of whom reported
that this symptom had occurred in the past month.
Bipolar disorder. About one in five of the depressed patients in
VA PC clinics reported being told they had bipolar disorder by a
doctor, with a roughly equivalent and overlapping percentage
reporting having taken medications suggestive of bipolar
disorder (e.g., lithium).
Anxiety. Nearly two-thirds reported feelings of persistent
anxiety in the previous 6 months. Just over 40% reported
having experienced a panic attack with sudden intense fear
and discomfort, over half of whom reported a month or more
during which anticipation of possible future panic attacks
changed their daily activities. One quarter of participants
reported one or more panic attacks in the past month.
Alcohol consumption. Nearly half of these depressed patients
reported drinking in the past year, with one in five reporting
reported using alcohol reported occasional-to-daily levels of toxic
drinking (i.e., 6+ drinks on one occasion for men, 4+ for women).
MH-related medication use. Over half (55.1%) had been
prescribed 1+ medications specifically for their mental or
emotional problems. Over a third of patients said their depression
medications, specifically, were “a little” to “not at all helpful.”
Physical and Mental Health Function
among Depressed Primary Care Patients
Physical and MH functional limitations were common (Table 2).
For example, nearly two-thirds of depressed PC patients
reported accomplishing less than desired in the past 4 weeks,
and limitations in the kinds of work or other activities they
were able to do. When asked about limitations related to
emotional problems (i.e., feeling depressed or anxious), over
half reported accomplishing less than desired, and over 40%
of emotional problems. Similarly, over half reported that their
physical or emotional problems interfered with their social
activities (e.g., visiting friends). Pain was also reportedly respon-
sible for significant interference with work (in and outside the
home). Sexual dysfunction was common and longstanding, with
nearly half of patients with sexual dysfunction reporting that it
was neither discussed with medical providers nor treated.
We found that practice-wide depression screening yielded about
20% positive PHQ-2 screens among veterans seen in primary
care (PC) and 12% probable major depression (or nearly 60% of
positive PHQ-2 screens). Among depressed patients in VA PC
settings, we noted highly prevalent comorbid mental illness (e.g.,
anxiety, PTSD) and substantial chronic disease burden.
Overall, veteran PC patients’ rates of depression are higher
than those of their civilian counterparts. Nationally, about 6.6%
of Americans are depressed in any given year (with a lifetime
prevalence of 16.2%).28These differences may reflect veterans’
service-connected disabilities that ensure their entrée to VA
health care and may place them at higher risk of depressive
symptoms. VA users also have 1–2 more chronic diseases than
same-age, same-gender, same race-ethnicity civilians, and
chronic disease burden has been linked to greater depression
in the VA have also continued to increase since the VA mandated
annual depression screening in 1998.31
Figure 1. Yield of depression screening in practice-based random
sample of primary care clinic visitors
Yano et al.: Yield of VA Depression Screening
The 20% positive-screen rate from practice-based screening is
substantially higher than most previously reported VA rates. For
example, VA performance measures, which rely on chart reviews
of random samples of clinic visitors to determine annual
screening yields, reflected 8.8% positive screens in the same
year our cohort enrollment began,32while chart reviews of
consecutive PC patients at a single VAyielded 7%.33Chart-based
assessment ofthe yield ofdepression screeningamong four other
VA clinics also demonstrated a 7% positive-screen rate, even
when veterans already in mental health or substance abuse
treatment were excluded.34Our use of patient self-report is likely
the key distinction, as our positive-screen rate is consistent with
another survey-based assessment of VA screening yield (also
20%) in a single site.16Our findings point to the importance of
systematic, practice-based screening—as recommended by the
VA/DoD clinical practice guidelines for depression—to not only
identify new cases but to identify patients for whom treatment
has been ineffective, who are no longer engaged in treatment or
who have relapsed, regardless of whether they have been
The severity of these veterans’ depression was substantial. We
found evidence of significant chronicity and personal and occu-
pational impairment. Further, while suicide and suicidal ideation
are common symptoms of depression, and mood disorders confer
increased risk of suicide,36,37we did not anticipate the level of
suicidal ideation (over 30%) among routine PC clinic visitors even
in the VA. However, other studies have noted comparable levels in
non-VA settings (using the PHQ-9).38,39In recognition of higher
rates of suicidality among veterans in general, the VA has
made suicide prevention a top priority, instituting a national
crisis hotline, confidential online chats, outreach and local
suicide prevention coordinators. The crisis line has answered
more than 400,000 calls and made more than 14,000
lifesaving rescues.40Ensuring that PC providers have the
training and organizational support they need to address the
severity of their patients’ depression is essential, while our
results have important implications for PC practices outside
the VA system.41
We also found considerable medical and mental health comor-
bidities among depressed patients in VA PC settings, rendering
most guideline adherence strategies relatively moot in the face of
these patients’ complex needs. Two-thirds reported comorbid
PTSD or symptoms of generalized anxiety or panic disorders,
while a significant proportion reported dangerous levels of alcohol
ought to assess tradeoffs in how they manage, medicate and/or
and mental health-related.42Given the mental health comorbid-
itiescommontoPCpatients withdepression, solomanagementby
PC providers is unlikely to be effective without organizational or
system supports that foster integrating mental health specialty
input in some efficient way. Even in settings where mental health
capacity is reasonably high, patient preferences (including con-
cerns about stigma) and barriers to effective handoffs preclude a
mental health-only solution.43Instead, collaborative care models
have demonstrated the value of shared care, where PC providers
are supported in the mental health care of their patients through
depression care managers who are supervised by mental health
providers.44,45In the absence of such care models, evidence
suggests that depression remains persistent.46
Over one third of the patients who reported being prescribed
one or more mental health-related medications reported they
were of limited to no benefit. In the absence of improved
medication management, most patients commonly undergo only
a single trial of antidepressants, resulting in insurers and health
care systems bearing the substantial costs of initiating inade-
quate depression treatment.47Systems cost-effectiveness also
demonstrates the value of the acute phase of depression
treatment.48As health plans, health care systems, clinics and
providers increasingly adopt depression screening guidelines, it
will be essential that systems are simultaneously put into place to
ensure adequate monitoring of symptoms between and during
visits, to support effective medication management and improved
outcomes for depression patients in PC settings.49
Although the design of this study does not permit definitive
differential psychiatric diagnoses, the potential comorbid mental
health conditions are likely to increase the difficulty of treating
anxiety, on top of one-third having substantial medical comorbid-
traditional 15–20-min medical appointment. This level of comor-
bidity is not unique to the VA. Most lifetime (72.1%) and 12-month
(78.5%) cases of depression have at least one comorbid CIDI/DSM-
IVdisorder, with major depressive disorder (MDD) only rarely being
primary.52Interestingly, there is little empirical evidence that these
types of complexities reduce the propensity of PC physicians to
diagnose mental health problems, though depressed patients with
comorbid anxiety have longer visit durations, greater depression
severity and are more likely to be diagnosed.53–55
What is also clear from this work is that PTSD is virtually a
hidden diagnosis in primary care. Previous studies have not
usually reported PTSD prevalence among depressed PC patients.
Primary care is operating as the “de facto mental health care
system…”56It is essential that PC providers be trained to screen
their patients for PTSD symptoms, as these patients tend to
present with somatic complaints or depression alone, and may
avoid discussion of their traumatic experiences.57
This study is not without limitations. Our data represent the
population of clinic users with probable major depression within
the VA. Its generalizabilityto the generalpopulation may therefore
belimited, althoughratesof depressionamongAmericansmaybe
an underestimate due in part to the relative lack of access to
mental health care outside the VA. Most comparative literature
also derives from chart reviews rather than telephone-based
patient self-report, which is itself not a common clinical practice
and could affect responses. While trained interviewers were used,
do not have comparison data for veterans with negative screens,
though another study reported such comparisons, and found no
sociodemographic or comorbidity differences.32We also did not
rate as both undiagnosed and diagnosed cases were included.
However, unless treatment initiation was very recent, we would
have expected to see more veterans scoring below the depression
threshold score. Our data are also from 2002–2004. Depression
care within the VA has evolved significantly in subsequent years,
in part as a result of the main trial’s findings.11
Given the prevalence of mental health disorders among
veterans using the VA health care system, the VA is an
exceptional laboratory for implementing and evaluating integrat-
ed primary care-mental health care delivery models.58Not
surprisingly, the VA is currently engaged in just such a national
effort, chiefly through a mix of strategies of co-located mental
health care, depression collaborative care arrangements, and/or
Yano et al.: Yield of VA Depression Screening
referral to a behavioral health laboratory.34,59–61Disease man-
agement programs that incorporate models like these, which
include evidence-based guidelines, patient/provider education,
collaborative care, reminder systems, and monitoring, have been
shown to have significant effects on depression severity across
of accelerating the implementation and spread of such models to
address the substantial needs of depressed veterans in VA
primary care settings, while also highlighting the importance of
continual practice-based screening and surveillance. Further,
since depression has historically been detected in only about
50% of cases, relying on clinician-documented major depression
screening using patient surveys is an important adjunct to
effective case finding, monitoring and quality improvement pro-
grams in primary care.
Acknowledgments: This project was funded by the Department of
Veterans Affairs (VA) Health Services Research and Development
(HSR&D) Service and the Quality Enhancement Research Initiative
(QUERI) (Project #MHI 99–375 and MNT 01–027). The manuscript
reflects baseline data from a group randomized trial (Trial Registration
No. NCT00105820). Dr. Yano is funded under a VA HSR&D Research
Career Scientist award (Project#05–195). Dr. Campbellwas funded by
a VA Office of Academic Affiliations (OAA) Associated Health Postdoc-
toral Fellowship Program at the Northwest Center for Outcomes
Research at the time the study was conducted; he is now Assistant
Professor at the University of Montana.
We would like to acknowledge key intervention team members,
including Susan Vivell, PhD, MBA, and Brad Felker, MD, as well as
project support staff, Carol Simons, Laura Rabuck, MPA, and Debbie
Mittman, MPA. Special recognition goes to the frontline efforts of the
original network-level depression care managers, including Karen
Vollen, RN, Barbara Revay, RN, and Bill Raney, as well as the site
principal investigators at participating facilities.
An earlier version of this work was presented as a poster at the
national meeting of the Society for General Internal Medicine (SGIM),
New Orleans, LA, May 13, 2005.
The views expressed in this article are those of the authors and do
not necessarily represent the views of the Department of Veterans
Affairs or the United States government.
Conflict of Interest: None disclosed.
Corresponding Author: Elizabeth M. Yano, PhD, MSPH; VA Greater
Los Angeles HSRD Center of Excellence, 16111 Plummer Street,
Mailcode 152, Sepulveda, CA 91343, USA| (e-mail: elizabeth.
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